"Two nurses and a doctor died from SARS. Almost half of those who got SARS in hospital were people who got SARS on the job from working there," wrote Justice Archie Campbell, who authored the 1204-page report, released on Jan 9, on behalf of the SARS Commission.

During Ontario's epidemic, which lasted from February through June 2003, the disease struck 375 people and killed 44.

One of the most glaring breakdowns in worker protections involved controversy about the use of N95 respirators, said the report. Few hospitals complied with a law requiring them to properly train and fit-test employees who used the respirators. The commission also found that some Ontario hospital officials argued against N95 respirator use on the grounds that healthcare workers could safely wear the less expensive surgical masks.

"If the Commission has one single take-home message it is the precautionary principle that safety comes first, that reasonable efforts to reduce risk need not await scientific proof," Campbell said in the report.

The commission identified several other shortcomings in Ontario's response to the crisis, including a lack of infection control expertise, poor communication between public health agencies and hospitals, nonfunctional health and safety committees, blurred authority and accountability, inadequate surveillance, minimization of the role of the Ministry of Labor, and failure to heed the advice of front-line healthcare workers.

In analyzing the events in Ontario, the commission several times contrasted the response of Ontario healthcare officials with the response in British Columbia, where a patient was also hospitalized at about the same time for SARS, but no major outbreak occurred.

"A combination of worker safety and infection control culture at Vancouver General, with better systemic preparedness, ensured that BC was spared the devastation that befell Ontario," Campbell pointed out. "The Commission is not surprised that in Vancouver, with its greater systemic awareness of and commitment to worker safety, only one health worker contracted SARS."

A spokesperson for Ontario Health Minister George Smitherman told Canadian Press (CP) the province would heed the commission's recommendations about the precautionary principle. "We take Justice Campbell's advice very seriously and we happen to agree with it," said David Spencer, Smitherman's press secretary. Smitherman was out of the country and unavailable for comment.

Specifically, Spencer said Smitherman supports the use of N95 respirators to protect healthcare workers in the event of an influenza pandemic, though a scientific debate on masks versus respirators continues. "If you take that to the issue of N95s, then that's something that we think is appropriate in the situation where you're talking about a pandemic," Spencer told CP.

However, Hilary Short, president of the Ontario Hospital Association, told CP her organization disagrees with the commission on that point. "We believe that you have to be very careful with personal protective equipment to use the science, because it's really safer to use the level of personal protective equipment that is called for by the science and not lead to the highest level of equipment."

One question the commission examined was whether political pressure influenced how the provincial government handled the SARS outbreak. The panel said it found no evidence of political or economic pressure to minimize or hide SARS or prematurely declare the SARS outbreak over. However, the report said communication between governments, agencies, and hospitals was often poor.

"SARS may be the last wake-up call we get before the next major outbreak of infection, whether it turns out to be an influenza pandemic or some other health crisis," Campbell wrote. "The tragedy of SARS, these stories of unbearable loss and systemic failure, give the public every reason to keep the government's feet to the fire in order to complete the initiatives already undertaken to make us safer from infectious disease."